Clinical perception and simple laboratory tests: do not mistake the finger pointing at the moon

Clinical perception and simple laboratory tests: do not mistake the finger pointing at the moon

Posted On
2016-12-27 16:41:16

Sometime in the past, in an urban emergency department (ED) of a large general hospital located somewhere around the globe, a patient entered the emergency room and asked to be seen by a doctor. He was a Caucasian male, aged around 62, smoker, with a history of type 2 diabetes, but not complaining for any particular symptom. He was simply “feeling bad”, thinking that he should be seen by a doctor. When the nurse completed the triage, and the patient was finally visited, he referred that same sensation of “feeling bad” to the emergency physician. As routine practice, the doctor ordered some first-line laboratory tests [a basic clinical chemistry profile, a complete blood cell count (CBC) and a cardiac troponin test] along with an electrocardiogram (ECG), to have a general picture of the health status. The test results, which were all available ~30 min afterward, revealed only two abnormalities. The value of cardiac troponin I (cTnI) was slightly above the 99th percentile of the assay (i.e., 52 vs. 36 ng/L), but still compatible with the age of the patient and the presence of diabetes (1). The only other abnormal finding was 19.0% of red blood cell distribution width (RDW), a value considerably higher than the upper limit of the reference range (i.e., 14.8%). The data emerged from the ECG were not suggestive for any typical cardiac disease, not the physical examination revealed meaningful issues. Yet, the patient insisted that he was feeling “bad”.